Reverend-Doherty-Application-REVISED-11-22-2024

Application for Heating Cost Assistance

Complete this section for the head of household

Name Last First Middle Initial

Home Address Street Apt Number City State Zip Code

Mailing Address if different from above Street Apt Number City State Zip Code

Email Address

example@example.com

Primary Residence Municipality

Select Those that Apply to You:

Renting With Heat Included in RentRenting With Heat NOT Included in RentOwn My Primary ResidenceOther

What is your primary heating source? (permanently installed - not "space" heaters):

Select any that apply to you

What utility company would funds be dispersed to? (primary or secondary heat source fuel provider)

Name of Utility Company or Fuel Dealer

Account Number

Address Street City State Zip Code

Name on Account

Do you have a secondary source of heat in your home? If yes, explain:

YesNo

If yes explain

Do you or any other member of your household receive any utility subsidies on a regular basis? (more than once a year)

YesNo

If yes explain

Have you or any other member of your household received a one-time utility subsidy? (once a 8 year or less)

YesNo

If yes explain

Section Have you or any other member of your household received benefit from the Reverend Doherty 9 Fuel Fund within the past 5-years?

YesNo

If yes when

List the people who live with you at this address. Include all children & adults. Include related roomers. Include all unrelated roomers who share household expenses. Do not include the 10 applicant listed in Section 1 of this application. Name (Last, First, Middle Initial)Date of Birth Relationship to You

First Name Last Name Date of Birth Relationship to you

Section Tell us about income (before taxes & deductions) for ALL people in your household. Include money from: Employment, Veteran's Benefits, Unemployment Compensation, Social Security, 12 Workers Compensation Interest & Dividends, Rental Income, etc. Name of Person with IncomeIncome Source Date of First Check Monthly Amount

Name of person with income Income Source Date of first check Monthly Amount

My signature on this application gives permission to the Borough of Honesdale &/or it's appointees to verify any information I have submitted on this application including but not limited to where I live, my household income, my energy supplier, etc. My signature also gives the Borough of Honesdale &/or its appointees permission to contact my energy supplier(s) regarding my billing & usage for program evaluation purposes. I authorize sharing of information between the Borough of Honesdale & my energy supplier, as needed solely for the purpose of determining my household's eligibility. I affirm that the home address listed in Section 1 is in fact my primary residence. I understand that if I am selected to receive benefit from the fund, payment will be remitted directly to my energy supplier. I acknowledge that in the event that the Borough of Honesdale receives more eligible applications than the dedicated fund can fulfill, recipients may be chosen at random. I certify that all information provided within this application is true, correct & complete to the best of my knowledge.

Print Name

Sign Name

Please use this checklist in conjunction with your application to ensure your application is complete.

Did you check Page 4 to confirm that you are eligible for assistance?Did you ensure that your primary residence is within the Borough of Honesdale?Did you fill out ALL required information clearly & completely?If you rent or own your home & pay for your own heat, enclose the most recent bill for your primary heating source . For other fuels, provide most recent bill or receipt of a purchase.If you are requesting payment to be sent to your secondary heating provider, enclose a copy of your primary AND secondary heating billEnclose proof of income in the form of two (2) most recent paystubs, employer statement, etc.If you listed no sources of income or your income is less than the cost of your monthly basic living needs, enclose a statement explaining how your household pays for basic living needs (food, rent, etc)Did you sign & date your application?

When you have completed the checklist & the application, remit by mail to:

Borough of Honesdale Reverend Doherty Fuel Fund 958 Main Street Honesdale, PA 18431

Subject: Reverend Doherty Fuel Fund Application

All completed applications, checklists & attachments will be accepted by email, mail or dropped off at Borough Hall.

You must meet the following income requirements:

2) You may rent/lease or own the dwelling at which you are requesting assistance.

3) The dwelling you are requesting heating assistance for MUST be your primary residence. Investment properties, rental properties, vacation homes, secondary homes, etc. are not eligible for assistance.

4)The dwelling you are requesting heating assistance for MUST be located within the Borough of Honesdale, Pennsylvania.

5) Your household will be ineligible to receive benefit this application period if a utility/heating bill for you or your household has been paid by the Reverend Doherty Fund two (2) times or more within the past two (2) calendar years.

*- Meeting elegibility requirements does not guarantee receipt of benefit from the fund. In the event that the Borough of Honesdale receives more eligible applications than the dedicated fund can fulfill, recipients may be chosen at random.